Screening Pap Smears: High Risk vs. Low Risk
Background
The screening Pap test detects significant abnormal cell changes that may arise before cancer develops. If diagnosed and treated early, any abnormal cell changes that may occur over time can be reduced or prevented.
Frequency
Medicare Part B has different reimbursement guidelines for the screening Pap smear based on the patient's risk factors for cervical cancer.
Medicare provides coverage of a screening Pap test for all female beneficiaries when the test is ordered and collected by a doctor of medicine, osteopathy or other authorized practitioner. For Medicare purposes, 'risk' is defined as follows:
- Low risk
- Covered once every 24 months/two years (at least 23 months have passed following the month in which the last covered screening Pap test was performed)
- For low risk, submit ICD-9 codes V76.2, V76.47, V76.49 or V72.31
- High risk
- Covered once every 12 months/one year (at least 11 months have passed following the month that the last covered screening was performed)
- For high risk, submit ICD-9 code V15.89
Definition of High Risk
Women are considered to be at high risk for cervical cancer if they:
- Are of childbearing age and have had an examination that indicated the presence of cervical or vaginal cancer or other abnormalities during any of the preceding three years
- Had multiple sex partners (five or more in a lifetime)
- Engaged in sexual activity before the age of 16
- Have a history of a sexually transmitted disease
- Had fewer than three negative Pap tests within the previous seven years
Coinsurance & Deductible
- HCPCS code Q0091- (collection of the specimen for a screening Pap test): the patient is responsible for the coinsurance. The patient does not have to meet the yearly deductible.
- HCPCS codes G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001- (screening Pap smear laboratory test): the patient is not responsible for any coinsurance and does not have to meet the yearly deductible
Reference:
- For additional information on the screening Pap test/smear, visit the CMS Web site